2. Anatomy
Kiesselbach’s plexus – responsible for >90%
Located at anterior nasal septum
Confluence of vessels:
INTERNAL CAROTID
Opthalmic -> Ant. Ethmoid
EXTERNAL CAROTID
Facial -> Superior labial
Maxillary -> Descending palatine -> Greater palatine
Maxillary -> Sphenopalatine
From the anatomical literature and drawings collection at
Heidelberg University—HeidICON
http://www.flickr.com/photos/double-
m2/sets/72157626344216704/
3.
4. Anatomy
Woodruff’s Plexus
Common cause of posterior bleeds
Lies inferior to posterior end of inferior turbinate
Confluence of vessels:
EXTERNAL CAROTID only
Maxillary -> Sphenopalatine
Ascending pharyngeal
Also be aware of retrocolumellar vein – 2mm posterior
to columella. Easily reachable by a child’s finger!
5. Classification
Multiple methods!
Main ones to remember are common sense:
ADULT v CHILDHOOD (bimodal distribution)
PRIMARY v SECONDARY (causal factor attributable
– more on this later!)
ANTERIOR v POSTERIOR – the one you’re likely to
hear on the wards. Piriform aperture used as
anatomical landmark
6. PRIMARY v SECONDARY
Primary or Idiopathic:
Accounts for 80%
Risk factors: Autumn/Winter, NSAIDS, Alcohol,
Hypertension
Secondary:
Trauma, Surgery, Anticoagulation, Hereditary
haemorrhagic telangiectasia
7. Management
The nose is part of the upper airway
Therefore MUST adequately assess Airway,
Breathing and Circulation
Often high incidence of co-morbidities, placing these
patients in high-risk bracket
Full history after resuscitation/stabilisation to elucidate
any underlying causes
Try and get estimate of loss but often difficult for
patients to accurately determine
8. Management
First Aid measures have often already been attempted
(badly!)
Pinch ala nasi – remember directly compresses anterior
source of majority of bleeds
IV Access and FBC/G&S (coagulation studies not
routinely required unless suspected abnormality from
history)
Detailed and accurate assessment of nose
Adequate light! (headlight ideally)
Semi-recumbent position if stable
Suction and topical vasoconstrictive solution +/- LA
Protective clothing/gloves/glasses
9. Therapeutic Ladder
As treatment ascends up ladder, specialist input from
ENT required
DIRECT vs INDIRECT therapy
10. Indirect
Used if no bleeding point identified
Nasal pack
As with bleed, can be anterior or posterior (or both!)
Traditionally BIPP ribbon gauze
Newer anterior packs – Merocel (sponge), Rapid Rhino (inflatable)
Posterior packs usually Foley catheter fed into post nasal space and
inflated, pulling forward until it lodges in posterior choanae.
Needs to be secured anteriorly with protection to columella skin (usually
with umbilical clip)
Very painful therefore warn patient and adequate analgesia! GA
sometimes necessary
Antibiotics required if pack remains longer than 48 hours (risk of toxic
shock syndrome)
11. Direct
Directly treat bleeding vessel – optimal for patient
Endoscope allows superior visualisation
Silver Nitrate cautery +/- direct haemostatic agents
If unsuccessful, ongoing uncontrolled bleed or
inadequate haemostasis from indirect techniques ------
------- THEATRE
12. Surgical management
Direct identification and cautery of bleeding point +/- further ant/post
packing
Sphenopalatine artery ligation
Transantral Maxillary artery ligation (classic approach)
External Carotid artery ligation (rarely required)
Anterior/posterior ethmoidal artery ligation – usually only required in
confirmed ethomidal bleeds e.g. traumatic injury
Also – septoplasty
13. And . . . .Embolisation
http://commons.wikimedia.org/wiki/File:MCA_an
gio_lateral.jpg
Courtesy of Dr Frank Gaillard
Very useful for intractable
haemorrhage surgically
inaccessible sites/non-operativ
candidates BUT highly
dependent on local radiologica
expertise
14. TAKE HOME MESSAGE
Epistaxis:
Can be a severe, life-threatening condition
High-risk patients with multiple co-morbidities
Range of treatment options: direct if possible
Early involvement of ENT team